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An Independent Licensee of the <br />Blue Cross and Blue Shield Association <br />PROPOSAL NOTES <br />STOP LOSS PROPOSAL FOR <br />Indian River County Board of County Comm <br />• The rates and factors in this proposal are firm. Please provide a signed proposal. <br />• Large claim data must be submitted for any claims that are at or have the likelihood to exceed 50% of the group specific deductible. Large claim <br />data must include: age, sex, diagnosis, prognosis, treatment plan, case management notes (if applicable), Pre -Cert and paid/pended claims. <br />• The Estimated Contract Attachment Point includes the Aggregate Corridor level as shown. To determine Estimated Expected Claims, you may <br />divide the Attachment Point or Attachment factors by the corridor level. <br />• The specific rates in this proposal are based on an aggregating specific arrangement. Total Specific Liability includes estimated contract specific <br />premium and the aggregating specific fund. <br />• Human Organ Transplant benefits are payable in accordance with the underlying plan and are subject to the proposed Lifetime Maximum Specific <br />Benefit offered within this proposal. <br />• This proposal includes a 50% rate cap on the Specific Premium Rate at the renewal of your stop loss policy. If applicable, this increase will also <br />apply to the Aggregating Specific Loss Fund. The rate cap does not apply to Material Changes, including but not limited to the following: <br />underlying plan document, our stop loss contract provisions, PPO network or TPA, and the rates may be further adjusted by such changes. The <br />rate cap rider applies to this policy term only. It may be offered at subsequent stop loss policy renewals at the discretion of Underwriting. <br />• At renewal we will not apply any new Special Risk Limitations including but not limited to an Alternate Specific Deductible or Excluded Claim <br />Expense unless requested. <br />PROPOSAL ACCEPTANCE <br />Leave of Absence (LOA) Policy for eligible employees is: Days or Weeks or Other and it is to be applied once per plan <br />year per member and only after FMLA allowance is exhausted. Leave Of Absence allowance need not be used in consecutive days, but total time <br />not actively at work during the plan year as a whole must not exceed the above outlined allowance plus the 90 day FMLA allowance. <br />In the absence of Leave of Absence language in the group plan document, the above will be considered as the LOA policy as it relates to Stop Loss <br />Eligibility and continuation of coverage only. Any subsequent changes must be approved by Florida Blue at least 30 days in advance of the effective <br />date of the change. Failure to notify Florida Blue of your company's policy changes for Leave of Absence may result in a possible Stop Loss claim <br />denial. Upon exhaustion of LOA benefits as described above, to continue Stop Loss eligibility members must be offered COBRA as outlined in the <br />"Continuation of Coverage Under Cobra" section in your Group Benefit Book. All other eligibility requirements beyond the LOA allowance described <br />here are outlined in the Group Benefit Book and apply to the Stop Loss in their entirety. <br />Please acknowledge acceptance of the terms in this proposal by signing and returning by 08/21/2020 (no signed proposal will be accepted after the <br />effective date). Please also indicate which option is chosen and whether Aggregate is to be included, by checking the appropriate boxes on the <br />previous page. Failure to remit the signed agreement within the same period,yviJlrasWt in updated large claim disclosure (and claims) being required <br />for our review. All payments after the effective date of this policy, found,oe, must use the rates selected. Any deviation from the <br />rates specified could result in an underpayment lea ' to a possible'c�`cellati n:✓F�;•.• <br />Signature: Title ��h <br />Accepted on the 18th day ofAugusIt 20 20 .•.• <br />APpROVF-D A5 TO P011t!." <br />Attest: Jeffrey R. Smith, Clerk of <br />;It Court and ComptrollerUnderwriter: KMC (July 27, 10683960576-2020-588385%'QTY A -i- � y Page 2 of 4 <br />Deputy Clerk <br />